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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM D TE ISSUED <br /> JOB ADDRESS 1181 Zuckerman Road �(�q7 II CITY/ZIP Stockton,CA 2 0 m <br /> CROSS STREET e APN�!// 10 M r PARCEL SIZE"AND USE APPLICATION# o <br /> m <br /> OWNER NAME PG&E PHONE ru'n <br /> OWNER ADDRESS 1181 Zuckerman Road CITY/STATE/LP Stockton,CA <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue. CITY/STATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR Kazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215W,Dakota Avenue CITY/STATE/ZIP Clovis.California 93612 <br /> LICENSE \/C-57 C-61 J D-09 Other NUMBER 499908 EXPIRATION DATE 10 31,2020 <br /> DOMESTIC WELL SAMPLING:I 1 General Mineral/Coliform Bacteria(4391)1 1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE i Domestic/Private F.Irrigation/Agricultural i Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I New Well Replacement Well G Well Alteration/Modification Other <br /> F1 Monitoring Well(s) #of wells C Soil Boring(s) #of borings f Geotechnical 5 If of borings <br /> I.i Out-Of-Service Well f_i Out-Of-Service Well Renewal Cross-Connection Repair (25-50 Feet) <br /> I New Pum i]Pump Replacement IJ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary D Air Rotary /Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter A Open Bottom 'Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter—A-in Thickness/Gauge/ASTM Sched ❑Steel 11 Plastic Stainless Steel i Other <br /> Grout Seal Deplh 5'-J�ft V,Neal Cement(94 to bag/5-10 gal water) ❑Sand Cement sack mlx17 gal water <br /> Bentonite(20%solids) U Other <br /> Grout Placement Method Pumped iJ Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick in r i Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level h <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 H AD AN NO TIC .REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE r -'`F TITLE Managirig Engineer DATE 12/6/2019 <br /> �E <br /> CE jVED <br /> DEC �2 2019 <br /> IV X7&0cou/v ?' <br /> T H D_�PAR MENT <br /> A�EMNT US O Y <br /> Application Accepted By e // 'r Area Employee I D# r tail <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By _ Date n� WAIVER Received <br /> Soil Boring Inspection By Date�7-0 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck#/ Amount D to PermiU Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> vFWP0040-3sl <br /> EHO 43-06 revised 4/14116 WELL/PUMP PERMIT <br />